Curly Toe

Key Points:

  • Curly toe is a common deformity which is usually bilateral.
  • Resolution is seen in about 20% of the cases
  • Surgical treatment (flexor tenotomy) is recommended if the deformity is symptomatic and persists beyond 6 years of age

Description:

This deformity consists of flexion and medial deviation of the toe. The adjacent toe may be overriding. It is most commonly seen in the third and fourth toes. It is usually bilateral and there is often a positive family history.

Epidemiology:

Clinical Findings:

Curly toes are often asymptomatic in children, but their appearance is vexing to many parents. They may cause pressure symptoms from shoe wear later in life, manifesting with calluses, blisters, or nail deformity. Exam demonstrates that the proximal interphalangeal (PIP) joint rests in a flexed position, with or without a flexion deformity of the distal interphalangeal (DIP) joint.  The absence of capsular contractures can be confirmed by full passive extension of the PIP and DIP joints while the metatarsal phalangeal (MTP) joint is held flexed.  There may be a varus posture of the toe with lateral rotation that leads to under riding of the adjacent toe. 

Imaging Studies:

Radiographs are not usually necessary in the evaluation and management of curly toes.

Etiology:

Contracture of flexor digitorum longus and/or brevis are responsible for this deformity.

Treatment:

The natural history of the curly toe is spontaneous resolution in approximately 25% of the cases (Sweetham, 1958). Taping may improve the posture temporarily, but the deformity usually recurs when taping is discontinued (Turner, 1987). Both simple tenotomy (Ross, 1984) and transfer of the long flexor to the extensor apparatus (Girdlestone-Taylor procedure) have been utilized for surgical correction. In a double blind study, there was no difference in results, and simple tenotomy suffices (Hammer et al, 1993). As a result of a long-term study, Biyani advocates no treatment before age 6 years, as the rate of spontaneous correction is so high (Biyani et al,1996). If treatment is necessary, tenotomy of the long and short toe flexors is recommended. 

Complications:

Infection and neurovascular injury are possible complications with surgical intervention.  Recurrence may be associated with a skin contracture resulting from a longitudinal plantar incision which crosses flexion creases.  Extensor tenotomy of the overlapping toe should be avoided as this may lead to a flexion deformity of the overlapping toe (Pollard, 1975).

References:

  1. Biyani A, Jones DA, Murray JM. Flexor to extensor tendon transfer for curly toes. 43 children reviewed after 8 (1-25) years. Acta Orthopaedica Scandinavica 1992; 63(4): 451-4.
  2. Hamer AJ, Stanley D, Smith TW. Surgery for curly toe deformity: a double-blind, randomized, prospective trial. Journal of Bone & Joint Surgery -British Volume 1993; 75(4): 662-3.
  3. Pollard JP, Morrison PJ. Flexor tenotomy in the treatment of curly toes. Proceedings of the Royal Society of Medicine 1975; 68(8): 480-1.
  4. Ross ER, Menelaus MB. Open flexor tenotomy for hammer toes and curly toes in childhood. Journal of Bone & Joint Surgery -British Volume 1984; 66(5): 770-1.
  5. Sweetham R. Congenital curly toes: An investigation into the value of treatment. Lancet 1958; 2(7043): 398-400.
  6. Turner PL. Strapping of curly toes in children. Australian & New Zealand Journal of Surgery 1987; 57(7): 467-70.

Top Contributors:

Pooya Hosseinzadeh